What Are the “Critical Elements” of Spine Surgeries?

Peer Reviewed

Radiographic localization, decompression, instrumentation, and fusion were defined as critical elements for common spine procedures evaluated in a consensus survey of spine surgeons, reported in the May 1 Issue of Spine. In contrast, patient positioning, fascial closure, and skin closure were not considered critical elements of spine surgery.
Surgeons in operating roomDecompression, instrumentation, and fusion were defined as critical elements for common spine procedures. Photo Source: 123RF.com.The findings are based on survey responses from orthopaedic (n=116) and neurological (n=37) spine surgeons who were members of AOSpine North America or the Society for Minimally Invasive Spine Surgery. The survey focused on the four of the most common spine procedures: anterior cervical discectomy and fusion (ACDF), open lumbar laminectomy and fusion (OLLF), microdiscectomy (MD), and posterior cervical laminectomy and fusion (PCLF). A surgical step selected by the majority of respondents (>50%) as “critical” for a given procedure was defined as a critical element in this study.

To better understand the survey findings and clinical implications, SpineUniverse spoke with lead author Joseph L. Laratta, MD, Spine Surgery Fellow and Clinical Instructor in the Departments of Orthopaedic Surgery and Neurosurgery at the Norton Leatherman Spine Center, University of Louisville Medical Center.

What was the purpose of this study?

Dr. Laratta: We sought to define the term “critical element” as it relates to operative spine procedures. The term is used colloquially between physicians and throughout operative dictation summaries. More formally, it has been central in the debate about the ethicality of concurrent surgery or overlapping surgery. For years, it has been used by CMS [Center for Medicare and Medicaid Services] in settings where residents are trained to qualify a procedure for reimbursement where the attending surgeon must be present for all “critical portions.” Interestingly, critical has never been defined.

What are the potential clinical implications of defining the “critical elements” of spine surgery?

Dr. Laratta: The results and statistical analysis of this cross-sectional expert opinion survey may be hard to digest at first. However, in general, radiographic localization, decompression, instrumentation, and fusion were considered “critical” for all procedures while patient positioning, fascial closure, and skin closure were not.

Before discussing the potential clinical implications, we must recognize and respect the limitations of the study. The study was only distributed to approximately 700 orthopaedic and neurosurgical spine surgeons across the United States—a relatively small sample of all practicing spine surgeons. Although comparable to most published survey studies in the orthopaedic literature, the response rate of 21.6% is not optimal. Ideally, to define criticality to a particular surgical step, we would include a more robust sample size with a more complete response rate and homogenous results.

There was significant variability in the responses when stratified by surgical subspecialty (orthopaedic versus neurosurgical), surgical setting (academic versus private practice), and surgeon experience (number of years in practice). I think, at the given time, we have inconclusive results and it is difficult to reach a general consensus regarding the critical steps of spine surgery. Until such a consensus is reached, the criticality of surgical steps should be defined by professional spine societies and the attending surgeon of record.

What impact may this determination of “critical elements” of spine surgery have on surgical training, billing, and the ethicality of concurrent surgery?

Dr. Laratta: In an academic setting with surgeons in training, establishing the critical elements of spine procedures will define the exact portions of the case in which the attending surgeon of record must be physically present in order to appropriately bill the Center for Medicare and Medicaid Services. In terms of ethicality of concurrent surgery, it is these exact portions in which the attending surgeon of record must be physically present for every case that is being performed. Concurrent operating rooms implement a graduated responsibility model for medical training. Graduated autonomy in the operating room is a fundamental part of surgical resident and fellow apprenticeship. As a society, it is important to recognize that this training is integral to the maturation of our next generation of surgeons. There is a limit to the amount of skill acquisition gained through observation. Although trainees need not perform critical parts of the procedure alone, performing surgery under a graduated supervision model is beneficial, as long as patient care is not compromised.

Is there anything else you would like to tell SpineUniverse readers?

Dr. Laratta: I would like to emphasize that at this point in time, we have no consensus regarding which portions of spine surgical procedures are “critical.” It is going to be an area of active research and focus in the future. Until such a consensus is reached, the criticality of surgical steps should be defined by professional spine societies and the attending surgeon of record.


Lali Sekhon, MD, PhD, FACS, FAANS
Spine Neurosurgeon
Nevada Neurosurgery
Reno, NV

The real issue here relates to informed consent for patients who may undergo overlapping or concurrent surgeries and the use of resident/fellow staff to assist in surgery. Patients are now being told that the attending will be present for the “critical portion” of the case. It is disappointing that there is no consensus on this subject. Ideally, academic surgeons would prefer that critical portions of the case involve only neural decompression or placement of implants. Hence, positioning, exposure and closure would be excluded from this definition of critical elements.

The private practice surgeon running one room and the academic surgeon using multiple rooms have different agendas and resources. The key points in the final summary of the article echo this dichotomy.

I am in private practice, and treat my patients like I would want to be treated. Generally, I am in the room starting from when the patient is anesthetized, and I position and mark the patient myself and close up the skin. I position, expose, and close better than my juniors. While they need to learn, they can do so supervised. It is important to remember that complications can happen at every phase.

A limitation of the paper is that it is a survey and, thus, has inherent biases and sampling issues. Many questions remain on this topic. For example, I think the interesting question is what would patients say is critical? What would hospitals and academic situations say is critical? If a patient develops blindness from poor positioning and there is a successful lawsuit, is that portion of the case no longer critical?

Dr. Laratta has received grants from the Orthopaedic Science Research Foundation, a fellowship grant from NuVasive, consulting/royalties from Evolution Spine (pending), travel/ accommodations from Stryker and K2M; and is on the Editorial Board of Spine and Global Spine Journal.

Dr. Sekhon is a consultant for Medtronic and AOSpine North America.

Updated on: 06/12/19
Continue Reading
QOL Improvements of Scoliosis Surgery in Children With Cerebral Palsy Outweigh Risks
Lali Sekhon, MD, PhD, FAANS, FRACS, FACS
Spine Neurosurgeon
Nevada Neurosurgery
Reno, NV

Get new patient cases delivered to your inbox

Sign up for our healthcare professional eNewsletter, SpineMonitor.
Sign Up!